Clinical Tests for the Musculoskeletal System - part 4 ppsx

Assessment: A patient with a subscapularis tear will be unable to do this. Infraspinatus Test Procedure: This test may be performed with the patient seated or standing. Comparative testing of both sides is best. The patient’s arms should hang relaxed with the elbows flexed 90° but not quite touching the trunk. The examiner places his or her palms on the dorsum of each of the patient’s hands and then asks the patient to externally rotate both forearms against the resistance of the examiner’s hands. Assessment: Pain or weakness in e x t e rn a l rotation indicates a dis order of the infraspinatus (external rotator). As infraspinatus tears are u sually painless, weakness in rotation strongly suggests a tear in this muscle. This test can also be performed with the arm abducted 90° and flexed 30° to eliminate involvement of the deltoid in this motion. Teres Test Procedure: The patient is standing and relaxed. Th e examiner assesses the position of the patient’s hands from behind. Shoulder 73 Fig. 72 Lift-off test Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. Assessment: The teres major is an internal rotator. Where a contrac- ture is present, the palm of the affected hand will face backward compared with the contralateral hand. With the patient standing in a relaxed position, such a finding suggests a contracture of the teres major. 74 Shoulder a b Fig. 73 Infraspinatus test Fig. 74a, b Teres test: a normal position, b contracture in the right arm Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. Weakness of the rotator cuff or a brachial plexus lesion can also produce an asymmetrical h and position. Nonspecific Supraspinatus Test Procedure: The patient is seated with the ar m abducted 90° with the examiner’s hand resting on the patient’s forearm. The examiner then asks the patient to further abduct the arm against the examiner’s resistance. Assessment: Weakness in further abduction and/or pain indicate path- ology of the supraspinatus tendon. Drop Arm Test Procedure: The patient is seated, and the examiner passively abducts the patient’s extended arm approximately 120°. The patient is asked to hold the arm in this position without support and then slowly allow it to drop. Assessment: Weakness in maintaining the position of the arm, with or without pain, or sudden dropping of the arm suggests a rotator cuff lesion. Most often this is d ue to a defect in the supraspinatus. In pseu- doparalysis, the patient will be unable to lift the affected arm. Th is global sign suggests a rotator cuff disorder. Shoulder 75 Fig. 75 Nonspecific supraspinatus test Fig. 76 Drop arm test Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. Ludington Sign Procedure: The seated patient is asked to place both hands behind th e neck. Assessment: If the patient has to make compensatory motions or is able to place one hand behind the neck only with assistance, the limited external rotation and abduction indicate the presence of a rotator cuff tear. Apley's Scratch Test Procedure: The seated patient is asked to touch the contralateral superior medial corner of the scapula with t h e index finger. Assessment: Pain elicited in the rotator cuff and failure to reach the scapula because of restricted mobility in external rotation and abduc- tion indicate rotator cuff pathology (most probably involving the supra- spinatus). A differential diagnosis should c onsider osteoarthritis in the glenohumeral and acromioclavicular joints as well as capsular fibrosis. 76 Shoulder Fig. 77 0° abduction test Fig. 78 Ludington sign Fig. 79 Apley's scratch test Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. Painful Arc Procedure: The arm is passively and actively abducted from the rest position alongside the trunk. Assessment: Pain occurring in abduction between 70° and 120° (Fig. 80b ) is a sign of a lesion of the supraspinatus tendon, which becomes impinged between the greater tubercle of the humerus and the acro- mion in this phase of the motion (subacromial impingement). (Contrast this with the painful arc in acromioclavicular joint disorders, where the pain only occurs only at 140°–180° of abduction, Fig. 80c ; see also Fig. 84 ). Patients are usually free of pain above 120°. In the evaluation of the active and passive ranges of motion, the patient can often avoid the painful arc by externally rotating the arm while abducting it. This increases the clearance between the acromion and the diseased tendinous portion of the rotator cuff, avoiding im- pingement in the range between 70° and 120°. Shoulder 77 a b c Fig. 80a–c Painful arc: a starting position, b painful motion between 30° and 120°, c pain at the end of the range of motion, a sign of acromioclavicular joint pathology. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. In addition to complete or incomplete rotator cuff tears, swelling and inflammation as a result of bursitis and abnormality of the margin of the acromion occasionally lead to impingement with a painful arc, as does osteoarthritis in the acromioclavicular joint. Neer Impingement Sign Procedure: The examiner immobilizes the scapula with one hand while the other hand jerks the patient’s arm forward, upward, and sideways (medially) into the scapular p lane. Assessment: If an impingement syndrome is present, subacromial constriction or impingement of the diseased area against the anterior inferior margin of the acromion will produce severe pain with motion. 78 Shoulder a b Fig. 81a, b Neer impingement sign: a starting position, b forcible forward flexion and adduction of the extended arm Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. Hawkins Impingement Sign Procedure: The examiner immobilizes the scapula with one hand while the other hand adducts the patient’s 90°-forward-flexed and internally rotated arm (moving it toward the contralateral side of the body). Assessment: If an im pingement syndro me is present, the supr aspina- tus tendon will become pinched beneath or against the coracoacromial ligament, causing severe pain on motion. Coracoid impingem ent is revealed by the adduction motion, in which the supraspinatus tendon also impinges against the coracoid process. In the Jobe impingement test, the forward flexed and slightly ad- ducted arm is forcibly internally rotated. This will provoke typical impingement pain. Shoulder 79 a b Fig. 82 Hawkins impingement sign: a starting position b forcible internal rotation (Jobe) Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. Neer Impingement Injection Test Procedure: The subacromial space is infiltrated with an ane sthetic. Assessment: This test allows the examiner to determine whether sub- acromial impingement is the cause of the painful arc. A painful arc that disappears or improves after the injection is caused by changes in the subacromial space, such as bursitis or an activated rotator cuff defect. ˾ Acromioclavicular Joint The acromial end of the clavicle articulates with the acromion. The acromioclavicular ligament reinforces the capsule of this joint. Func- tionally, the articulation is a ball-and-socket joint whose range of mo- tion is less than that of the sternoclavicular joint. Another strong liga- ment joins the scapula and clavicle, the coracoclavicular ligament. It arises from the coracoid process and inserts into the inferior aspect of the clavicle. Arthritic changes in the acromioclavicular joint cause pain and further constrict the subacromial space. In addition to pain with motion and tenderness to palpation over the acromioclavicular joint, findings will often include palpable bony thickening of the articular 80 Shoulder Fig. 83 Neer impingement injection test Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. margin. Tossy classifies acromioclavicular joint injuries into three de- grees of severity: Tossy type 1: Contusion of the acromioclavicular joint without signif- icant injury to the capsule and ligaments. Tossy type 2: Subluxation of the acromioclavicular joint with rupture of the acromioclavicular ligaments. Tossy type 3: Dislocation of the acromioclavicular joint with additional rupture of the coracoclavicular ligaments. In severe injuries to the capsule and ligaments, the pull of the cervical musculature causes the lateral end of the clavicle to displace proximally. From there it can be reduced inferiorly against elastic resistance. This procedure is sometimes referred to as the “piano key” phenomenon. Painful Arc Procedure: The patient’s arm is passively and actively abducted from the rest position alo ngside the trunk. Assessment: Pain in the acromioclavicular joint occurs between 140° and 180° of abduction. Increasing abduction leads to increasing com- Shoulder 81 a b c Fig. 84a–c Painful arc: a starting position, b pain between 30° and 120°(sign of a supraspinatus syndrome), c pain between 140° and 180° (sign of osteoarthritis in the acromioclavicular joint) Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. pression and contortion in the joint. (In an impingement syndrome or a rotator cuff tear, by comparison, pain symptoms will occur between 70° and 120°; see Fig. 80 ). Forced Adduction Test Procedure: The 90°-abducted arm on the affected side is forcibly adducted across the chest toward the normal side. Assessment: Pain in the acromioclavicular joint suggests joint pathol- ogy or anterior impingement. (Absence of pain after injection of an anesthetic is a sign of joint disease.) Forced Adduction Test on Hanging Arm Procedure: The examine r grasps the upper arm of the affected side with one hand while th e other hand rests on the contralateral sh oulder and immobilizes the shoulder girdle. Then the examiner forcibly a d- ducts the hanging affected arm behind the patient’s back against the patient’s resistance. 82 Shoulder Fig. 85 Forced adduction test Fig. 86 Forced adduction test on hanging arm Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license. [...]... Snap Test Tests for subluxation of the long head of the biceps tendon Procedure: The examiner palpates the bicipital groove with the index and middle finger of one hand With the other hand, the examiner grasps the wrist of the patient’s arm (abducted 80°–90° and flexed 90° at the elbow) and passively rotates it at the shoulder, first in one direction and then the other Assessment: Subluxation of the long... with the elbow flexed 90° The examiner immobilizes the patient’s elbow with one hand and places the heel of the other hand on the patient’s distal forearm The patient is then asked to externally rotate his or her arm against the resistance of the examiner’s hand Assessment: Pain in the bicipital groove or at the insertion of the biceps suggests a tendon disorder Pain in the anterolateral aspect of the. .. Buckup, Clinical Tests for the Musculoskeletal System © 20 04 Thieme All rights reserved Usage subject to terms and conditions of license 92 Shoulder Anterior Apprehension Test Tests of shoulder stability Procedure: The examination begins with the patient seated The examiner grasps the humeral head through the surrounding soft tissue with one hand and guides the patient’s arm with the other hand The examiner... proximally with the pull of the cervical musculature and can be pressed inferiorly against elastic resistance Dugas Test Procedure: The patient is seated or standing and touches the contralateral shoulder with the hand of the 90°-flexed arm of the affected side Fig 87 Test of horizontal mobility of the lateral clavicle Fig 88 Dugas test Buckup, Clinical Tests for the Musculoskeletal System © 20 04 Thieme All... of the biceps tendon out of the bicipital groove will be detectable as a palpable snap Yergason Test Functional test of the long head of the biceps tendon Procedure: The patient’s arm is alongside the trunk and flexed 90° at the elbow One of the examiner’s hands rests on the patient’s shoulder and palpates the bicipital groove with the index finger while the other hand grasps the patient’s forearm The. .. supinate the forearm against the examiner’s resistance This places isolated tension on the long head of the biceps tendon Assessment: Pain in the bicipital groove is a sign of a lesion of the biceps tendon, its tendon sheath, or its ligamentous connection via the transverse ligament The typical provoked pain can be increased by pressing on the tendon in the bicipital groove Buckup, Clinical Tests for the Musculoskeletal. .. “snapping” of the tendon Nonspecific Biceps Tendon Test Procedure: The patient holds the arm abducted in neutral rotation with the elbow flexed 90° The examiner immobilizes the patient’s elbow with one hand and places the heel of the other hand on the patient’s distal forearm The patient is then asked to externally rotate his or her arm against the resistance of the examiner’s hand Assessment: Pain in the bicipital... abduction Buckup, Clinical Tests for the Musculoskeletal System © 20 04 Thieme All rights reserved Usage subject to terms and conditions of license  94 Shoulder Assessment: The patient with anterior instability expects pain the farther the humeral head moves anteriorly past the labrum in the direction of potential dislocation The patient reacts with an avoidance movement Rowe Test Procedure: The patient stands... anteroposterior direction with the thumb Buckup, Clinical Tests for the Musculoskeletal System © 20 04 Thieme All rights reserved Usage subject to terms and conditions of license Shoulder Fig 108 test 99 Posterior apprehension The examination may also be performed with the patient seated With the patient in a relaxed posture bending slightly forward with the arm hanging alongside the trunk, the examiner places... of the rotator cuff, especially the infraspinatus tendon Abbott-Saunders Test Demonstrates subluxation of the long head of the biceps tendon in the bicipital groove Procedure: The patient’s arm is externally rotated and abducted about 20° The examiner slowly lowers the arm from this position The examiner guides this motion of the patient’s arm with one hand while resting Buckup, Clinical Tests for the . Sign Procedure: The patient is seated with the arm extended at the elbow and the forearm in supination. The examiner grasps the posterior aspect of the patient’s forearm. The patient is then asked to flex the. about 20°. The examiner slowly lowers the arm from this position. The exam- iner guides this motion of the patient’s arm with one hand whi le resting 84 Shoulder Buckup, Clinical Tests for the Musculoskeletal. about 20°. The examiner slowly lowers the arm from this position. The exam- iner guides this motion of the patient’s arm with one hand whi le resting 84 Shoulder Buckup, Clinical Tests for the Musculoskeletal